Mood Disorders

• Grief reaction:
• --Normal reaction to loss
• --Related to significant loss
• --Stop normal activities
• --Focus on present feelings & needs
• --Adjustment is the outcome
• Grief reaction can become abnormal:
• --Depression can be a distorted grief reaction.
• --Grief can become pathological grief reaction

• Anger & anxiety
• Apathy & bitterness
• Dejection & guilt
• Denying feelings
• Sad and despondent
• Helpless & hopeless
• Loneliness
• Low self-esteem
• Worthlessness

• Ambivalence
• Confusion, uncertainty
• Unable to concentrate
• Indecisiveness/loss of motivation
• Loss of interest
• Pessimism & self- depreciation
• Self-destructive thoughts 
• Suicidal ideation. At risk when pt has lost hope of recovery.

• Aggressiveness
• Immobility
• Agitation
• Decreased activity. Requires prompting to accomplish ADLs. 
• Intolerance/anger
• Irritability
• Lacks spontaneity
• Suicidal gestures & acts
• Underachievement
• Withdrawal
• Poor hygiene & lack of ADLs
• Dependent
• Social isolation/withdrawn
• Tearful
• Alcoholism & drug use-
• Self-medication

• Decreased 5HT (serotonin) and/or NE (norepinephrine)
• Women
• People with chronic, debilitating illness
• History of depression
• Concurrent psychiatric illnesses:
• -  Substance Abuse/Dependence
• -  Panic disorder
• -  Bipolar disorder
• -  Obsessive-compulsive disorder
• Prior suicide attempts
• Negative Evaluation of Self
• -  Pessimism & negative evaluation of self/others/world
• -  Cognitive distortions and faulty thinking
• Lack of social support
• Stressful life events
• Personal history of sexual abuse
• Sexual orientation issues
• People with unresolved grief
• Humiliating life event

When it lasts more than 2 weeks. 

When a depressed pt can no longer experience pleasure in an activity they used to find pleasurable. 

• When depression lasts 2 or more years. May occur in a pattern with more days depressed than not.
• Symptoms are generally not as severe as with major depression. 

• Psychoanalytic: associated with loss & is anger turned inward against the self
• Beck-Cognitive Therapy: Negative and faulty thinking 
• Neurochemical imbalance: Low levels of 5HT (serotonin)/ Low levels of norepinephrine

• Administer Medications (See Medication Sheet):
• --SSRI’s
• --Tricyclics
• --MAO inhibitors
• --Others antidepressants
• Monitor medication side effects, especially loss of appetite. Must be getting food/fluids. 
• Assess suicidal ideation
• 1:1 for short periods
• Cognitive restructuring for thinking
• Deal with anger and externalize as needed
• Avoid acting cheerful
• Mute-make observations of patient’s  response to environment & document
• Use simple, concrete words and sentences
• Work on problems to gain acceptance of self
• Cognitive restructuring for distortions in thinking
• What to do for paradoxical calm? Paradoxical calm is when pt with suicidal ideation suddenly gets better because they've come up with a plan, and having a plan makes them feel good. Do not d/c and watch closely for suicide attempts.

• 
• Seratonine Synapse Reuptake Inhibitor.
• Blocks seratonine's ability to taken up when it does not enter a receptor. 

• “Are you thinking about killing yourself?”
• “Have you thought about hurting yourself?”
• “When people are as upset as you seem to be, they sometimes wish they were dead.  I’m wondering if you are thinking about harming yourself?”
• Presence of a plan & lethality
• “Are you thinking about hurting yourself right now?  If that changes, will you promise to talk with someone before you make an attempt?”
• Nurse’s role in documentation
• Assess overt/covert cues
• --Covert: Hoarding clues, giving things away, saying good-bye, getting affairs in order.

• Ask directly about suicidality
• Document patient safety and action taken
• Unit & patient searches to provide safe environment 
• Remove harmful objects
• Suicide precautions
• 15 min, 30 min. and hourly checks
• 72 hour holds
• Monitor patient closely
• Sitter for extreme suicidality
• Line of site
• Watch for elopement

• Electroconvulsive Therapy: Thought to increase dopamine, serotonin, and norepinephrine by various mechanisms
• Vagus Nerve Stimulator: Placement of internal device used for epilepsy
• Functional EEG: matching of medication

• Elevated mood including 3 of the following: 
• Inflated self-esteem or grandiose
• Decreased sleep
• Increase talkativeness  
• Pressured speech: speaking on top of yourself. Words cannot flow fast enough. 
• Flight of ideas 
• Thoughts racing
• Distractible 
• Agitation
• Increase in goal-directed activity (socially, at work or sexually)
• Excessive involvement in pleasurable activity
• Sexual indiscretions, buying sprees, foolish business investments

• About the same as mania, but less and no psychotic symptoms. 
• Less severe than for mania
• Less impairment in social/occupational functioning
• Does not usually need hospitalization

• I: Is predominately manic with a few depressed episodes
• II: Is predominately depressed with a few manic or hypomanic episodes.  Harder to diagnose

Both are genetic and are characterized by a chemical imbalance in the brain.

• More amendable for treatment
• Symptoms similar to Major Depression
• Monitor for suicidal ideation
• Medication used to treat are different
• Use of Mood Stabilizers
• Antidepressants used with caution since they can precipitate manic episodes

• Administer medications & monitor side effects (1st line intervention is Rx)
• --Lithium (Therapeutic vs toxic levels)
• --Tegretol
• --Depakote 
• --Others
• Administer low doses of antipsychotics, to decrease impulsive behaviors. 
• PRN Benzodiazepines: helps to focus and relax. 
• Give finger foods. 
• Give fluids to drink
• --Want high calories because they will be burning them at a tremendous rate. 
• Do not laugh at jokes
• Use firm, calm approach
• Use short, simple words & explanations
• Be consistent with approach
• Set limits on behavior
• Provide a structured environment
• Avoid power struggles
• Send to room to calm down if escalates
• De-escalate
• Use time outs
• Distraction
• Redirect energy constructively
• Protect from self harm
• Remain calm

• Vary narrow therapeutic level. 
• (Level indicates multiple above therapeutic level.) 
• 2.0 level:
• Anorexia
• Nausea/vomiting
• Diarrhea
• Coarse hand tremor
• Twitching
• Lethargy
• Hyperactive deep tendon reflexes
• Tinnitus
• Vertigo
• Weakness
• Drowsiness

• Over 2.5:
• Fever,
• decrease urine output,
• decreased BP,
• irregular pulse, 
• ECG changes,
• impaired consciousness,
• seizures,
• coma and death